Specific improvement measures to reduce complications and mortality after urgent surgery in complicated abdominal wall hernia

The evolution of incisional hernia repair in Spain. A comparative analysis of results from the EVEREG registry

BACKGROUND

The aim of this study was to assess the utility of the EVEREG registry in evaluating the evolution of surgical treatment for incisional hernia and its outcomes in Spain by comparing data from 2 study periods.

METHODS

A retrospective comparative analysis of hernia surgeries performed between 2011 and 2015 (first period) and between 2017 and 2022 (second period) was conducted using data collected from the EVEREG registry.

RESULTS

Statistically significant differences were observed in the second cohort, including: a decrease in minimally invasive procedures (11.7% vs 8.2%; P < .001), an increase in emergency surgeries for males (31.7% vs 41.2%; P = .017), an increase in trocar hernia repairs (16% vs 26.2%; P < .0001), a reduction in suture repairs (2.8% vs 1.5%; P < .0001), and an increase in retromuscular techniques (36.4% vs 52.4%; P < .001) in open surgery with mesh. In elective surgery, there was a decrease in the average length of stay (4.9 vs 3.8 days; P < .0001), the percentage of complications (27.9% vs 24.0%; P < .0001), reoperations (3.5% vs 1.4%; P < .0001), and mortality (0.6% vs 0.2%; P = .002). Long-term outcomes included a decrease in recurrences after 12 months (20.7% vs 14.5%; P < .0001) and in chronic pain (13.7% vs 2.5%; P < .0001) and chronic infections (9.1% vs 14.5%; P < .0001) after 6 months.

CONCLUSION

In recent years, there has been a significant improvement in the outcomes of incisional hernia treatment. The registry serves as a fundamental tool for assessing the evolution of hernia treatment and enables the identification of key areas for improvement and the evaluation of treatment outcomes.

Associations Between Care Bundles and Postoperative Outcomes After Major Emergency Abdominal Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Care bundles were found to improve postoperative outcomes in elective surgery. However, in major emergency general surgery studies show a divergent impact on mortality and length of stay. This meta-analysis aimed to evaluate associations between care bundles and mortality, complications, and length of stay when applied in major emergency general surgery.

METHODS

A systematic literature search in PubMed and Embase was performed on the May 1, 2021. Only comparative studies on care bundles in major emergency general surgery were included. Meta-analysis and trial sequential analysis were performed on 30-d mortality. We undertook a narrative approach of long-term mortality, complications, and length of stay.

RESULTS

Meta-analysis of 13 studies with 35,771 patients demonstrated that care bundles in emergency surgery were not associated with a significant reduction in odds of 30-d mortality (odds ratio = 0.8, 95% confidence interval 0.62-1.03). Trial sequential analysis confirmed that the meta-analysis was underpowered with a minimum of 78,901 patients required for firm conclusions. Seven studies reported complication rates whereof six reported lower complication rates using care bundles.

CONCLUSIONS

Care bundles were reported to decrease postoperative complications in five out of seven studies and seven out of 11 studies reported a shortening in length of stay.

The effects of COVID-19 pandemic on emergency anterior abdominal wall hernia surgery: is it safe to postpone elective hernia surgery in the pandemic?

BACKGROUND

The aim of this study was to investigate the effects of the COVID-19 pandemic on emergency anterior abdominal wall hernia surgeries (EAAWHS) by comparing the pandemic period with the control period a year ago and to share our experiences in the pandemic period.

METHODS

This single-center retrospective cohort study included all patients who underwent EAAWHS during the pandemic (from 11 March 2020 to 25 January 2021) and control period (1 year before the same period, from 11 March 2019 to 25 January 2020). Demographic data, preoperative clinical and pathological parameters, intraoperative findings and postoperative complications secondary to operation and COVID-19 infection, length of intensive care and hospital stay of patients were recorded, and the pandemic and control groups were compared.

RESULTS

Of the 87 patients who underwent anterior abdominal wall hernia surgery during the COVID-19 pandemic, 41 (47.1%) were operated emergently and 46 (52.9%) were operated electively. Of the 485 patients who underwent anterior abdominal wall hernia surgery during the control period, 24 (4.95%) were operated emergently and 461 (95.05%) were operated electively. The decrease in the number of elective operations and the increase in the number of emergency operations were significant during the pandemic (p < 0.001).There was a decrease in the number of emergency inguinal hernia operations and an increase in the number of emergency ventral (incisional, umbilical) hernia operations during the pandemic period compared to the control period (p < 0.05).The mortality rates were similar (8.3 vs. 9.8%, p > 0.05) in both periods.

CONCLUSION

Despite the increase in the number of EAAWHS during the COVID-19 pandemic, there was no significant difference in mortality and morbidity rates. EAAWHS can be performed safely during the pandemic by taken necessary and adequate precautions.

Emergency hernia surgery at a high-volume tertiary centre: a 3-year experience

BACKGROUND

Hernia surgery is often considered minor. However, emergency abdominal wall hernia (AWH) surgery is associated with significant morbidity. This study reviews a high-volume centre's experience.

METHODS

This is a retrospective review of all emergency AWH operations performed between 2014 and 2017. The following were analysed: patient demographics, ASA grade, type of hernia, time from admission to surgery, use of pre-operative imaging, sac content, details of bowel resection, rate of admission to high dependency unit (HDU)/intensive care unit (ICU), length of stay and morbidity/mortality.

RESULTS

A total of 198 cases were included. Median age was 67.4 years (range 19-95). 52.2% of patients were ASA III or above. Median time from admission to surgery was 13 h (range 1-341) and median length of stay was 4 days (range 1-75). The sac contained bowel in 93 cases (47.0%). These patients had longer length of stay (P < 0.01) and were more frequently admitted to HDU/ICU (P < 0.01). Thirty-one patients underwent bowel resection (33.3% of those with bowel involvement and 15.7% of the total). Twenty-seven patients (13.6%) were admitted to HDU/ICU post-operatively. Six patients (3.0%) had an unplanned return to theatre and 66 patients (33.3%) had a post-operative complication. Inpatient mortality was three (1.51%).

CONCLUSIONS

Patients who undergo emergency AWH surgery represent a relatively aged and co-morbid group. This surgery is associated with significant morbidity and consumes considerable hospital resources. Efforts should be made to identify the higher risk subgroup with bowel involvement. Elderly and co-morbid patients should be listed for timely elective surgery wherever suitable.

Abdominal wall surgery after SARS-CoV-2: Time to reestablish postponed non-essential procedures?

Pandemic by the COVID-19 has found us unprotected to provide an adequate and rapid sanitary response. The hospital network of our public health system has provided most of the resources for the treatment of patients affected by the infection. Non-essential (non-priority) surgeries have been postponed. The optimal and proportionate reestablishment of these non-priority surgeries can be a problem. This article offers a technical and non-technical view of reestablishment non-priority surgeries from the perspective of abdominal wall surgery.

Does preoperative enhanced CT predict requirement of intestinal resection in the patients with incarcerated myopectineal hernias containing small bowel?

PURPOSE

Bowel wall enhancement on CT imaging is considered one of the useful features for the prediction of the presence of irreversible ischemic change in patients with small bowel obstruction. However, the applicability of CT imaging in patients with incarcerated hernias has not been investigated in detail. The aim of this retrospective study was to evaluate the feasibility of preoperative CT findings for the prediction of the presence of irreversible ischemic change in patients with incarcerated hernias containing small bowel.

METHODS

Included in this study were 76 patients who underwent surgery for preoperatively diagnosed incarcerated hernias containing small bowel (27 inguinal hernias, 37 femoral hernias and 12 obturator hernias) at our hospital between January 2011 and June 2020. The preoperative clinicoradiological features were compared between the groups, and predictors for intestinal resection were evaluated.

RESULTS

Nineteen patients required intestinal resection (Resection group), and the other 57 patients did not require intestinal resection (Nonresection group). Multivariate analyses revealed that age ≥ 80 years (p = 0.018, odds ratio = 6.604) and the absence of bowel wall enhancement (p = 0.032, odds ratio = 51.200) were independent predictors for intestinal resection. In resected specimens, all patients with an absence of bowel wall enhancement on preoperative enhanced CT had ischemic changes extending beyond the muscularis propria.

CONCLUSIONS

Preoperative enhancement CT yields useful information for the prediction of the presence of irreversible ischemic change in patients with incarcerated hernias containing small bowel.

Delay in emergency hernia surgery is associated with worse outcomes

BACKGROUND

Patients requiring emergent surgery for hernia vary widely in presentation and management. The purpose of this study was to determine if the variation in timing of urgent surgery impacts surgical outcomes.

METHODS

The national NSQIP database for years 2011-2016 was queried for emergent surgeries for abdominal hernia resulting in obstruction or gangrene by primary post-op diagnosis. Diaphragmatic hernias were excluded. Patients were grouped by surgical timing from admission to day of surgery: same day, next day, and longer delay. Multinomial propensity score weighting was used to address potential differences in underlying covariates' clustering across the timing groups followed by multivariable logistic regression of morbidity and mortality.

RESULTS

Weighted analysis yielded an effective sample size of 76,364. Hernia types included inguinal (20.9%); femoral (6.7%); umbilical (20.2%); ventral (41.0%); and other (10.4%). Delayed surgery was associated with increased rates of major complications (26.4% vs. 20.9%, p < 0.001), longer operative times (+ 12.5 min, p < 0.001), longer postoperative lengths of stay (+ 1.6 days, p < 0.001), increased re-operations (5.9% vs. 4.7%, p = 0.019), increased readmissions (7.0% vs. 5.7%, p = 0.004), and increased 30-day mortality (2.4% vs. 1.7%, p = 0.002). When controlling for other factors, next-day surgery (OR 1.23, 95% CI 1.05-1.45, p = 0.009) and surgery delayed more than one day (OR 1.40, 95% CI 1.13-1.73, p < 0.002) were associated with an increased odds of a major complication. Mortality and readmission by timing of surgery were not independently significant.

CONCLUSIONS

Delay in surgery for emergent hernias increased the odds of major morbidity but not mortality. Patients presenting with hernia and an indication for urgent surgical intervention may benefit from an operation as soon as feasible rather than warrant waiting for further physiologic optimization, medical clearance, or specialized surgical personnel.

Emergency surgery of the abdominal wall hernias: risk factors that increase morbidity and mortality-a single-center experience

PURPOSE

Morbidity and mortality are higher in urgently operated abdominal hernia cases compared to elective surgeries. The present study aims to investigate the factors that cause increased morbidity and mortality in emergency surgical operations.

METHODS

The files of a total of 426 patients who were operated for non-reducible abdominal hernia between 2015 and 2020 were reviewed retrospectively. Patients' ages, genders, comorbidities, Charlson Comorbidity Index (CCI), ASA score, BMI, hernia types, duration of symptom, laboratory values, intestinal strangulations or necroses, whether intestinal resection was performed, whether mesh was preferred for hernia repair, and rates of morbidity and mortality were recorded. Factors affecting morbidity and mortality rates were analyzed.

RESULTS

Factors such as gender, BMI (> 30), duration of symptom (> 24 h), presence of bowel necrosis and resection, type of hernia and prolonged operation time were found to cause an increase in morbidity. In the multivariate analysis, however, gender, duration of symptom and BMI (> 30) were statistically significant factors causing increased morbidity (p = 0.009, p < 0.001, p = 0.032, respectively). Advanced age, high ASA scores, CCI and duration of symptom were determined as factors affecting the increase in mortality. In the multivariate analysis, the effect of high ASA scores and advanced age on high mortality rate was statistically significant (p < 0.023, p = 0.039, respectively).

CONCLUSIONS

The mortality rate is higher, especially in elderly patients with high comorbidity. Therefore, we argue that the cases of abdominal wall hernia should be operated under elective conditions even if they do not give any clinical findings to prevent problems in older ages.

[Abdominal Wall Surgery After SARS-CoV-2: Time to Reestablish Postponed Non-essential Procedures?]

La pandemia por el COVID-19 nos ha encontrado desprotegidos ante la dificultad para dar una respuesta sanitaria adecuada y rápida. La red de hospitales del sistema sanitario público ha dispuesto la mayoría de los recursos para el tratamiento de los pacientes afectos por la infección. Las cirugías no esenciales (no prioritarias) han sido aplazadas. El reinicio óptimo y proporcionado de estas cirugías no prioritarias puede representar un problema. En el presente artículo se ofrece una perspectiva técnica y no técnica del reinicio de las cirugías no prioritarias desde la óptica de la cirugía de la pared abdominal.

Emergency repair of complicated abdominal wall hernias: WSES guidelines

PURPOSE

In July 2013, the World Society of Emergency Surgery (WSES) held the first Consensus Conference on emergency repair of abdominal wall hernias in adult patients with the intention of producing evidence-based guidelines to assist surgeons in the management of complicated abdominal wall hernias. Guidelines were updated in 2017 in keeping with varying clinical practice: benefits resulting from the increased use of biological prosthesis in the emergency setting were highlighted, as previously published in the World Journal of Emergency Surgery. This executive summary is intended to consolidate knowledge on the emergency management of complicated hernias by providing the broad readership with a practical and concise version of the original guidelines.

METHODS

This executive manuscript summarizes the WSES guidelines reporting on the emergency management of complicated abdominal wall hernias; statements are highlighted focusing the readers' attention on the main concepts presented in the original guidelines.

CONCLUSIONS

Emergency repair of complicated abdominal hernias remains one of the most common and challenging surgical emergencies worldwide. WSES aims to provide an essential version of the evidence-based guidelines focusing on the timing of intervention, laparoscopic approach, surgical repair following the Centers for Disease Control and Prevention (CDC) wound classification, antimicrobial prophylaxis and anesthesia in the emergency setting.

2017 update of the WSES guidelines for emergency repair of complicated abdominal wall hernias

Emergency repair of complicated abdominal wall hernias may be associated with worsen outcome and a significant rate of postoperative complications. There is no consensus on management of complicated abdominal hernias. The main matter of debate is about the use of mesh in case of intestinal resection and the type of mesh to be used. Wound infection is the most common complication encountered and represents an immense burden especially in the presence of a mesh. The recurrence rate is an important topic that influences the final outcome. A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013 with the aim to define recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel. In 2016, the guidelines have been revised and updated according to the most recent available literature.

Delayed repair of obstructing ventral hernias is associated with higher mortality and morbidity

BACKGROUND

Patients presenting with ventral hernia-related obstruction are commonly managed with emergent ventral hernia repair (VHR). Selected patients with resolution of obstruction may be managed in a delayed manner. This study sought to assess the effect of delay on VHR outcomes.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program database from 2005 to 2011 was queried using diagnosis codes for ventral hernia with obstruction. Those who underwent repair over 24 hours after admission were classified as delayed repair. Preoperative comorbid conditions, American Society of Anesthesiology (ASA) scores, and 30-day outcomes were evaluated.

RESULTS

We identified 16,881 patients with a mean age of 58 ± 15 years and body mass index of 36 ± 10. Delayed repair occurred in 27.7% of the patients. After controlling for comorbidities and ASA score, delayed VHR was independently associated with mortality (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.41 to 2.48, P < .001), morbidity (OR 1.4, 95% CI 1.24 to 1.50, P < .001), surgical site infection (OR 1.2, 95% CI 1.03 to 1.35, P = .016), and concurrent bowel resection (OR 1.2, 95% CI 1.03 to 1.34, P = .016).

CONCLUSIONS

VHR for obstructed patients is frequently performed over 24 hours after admission. After adjusting for comorbid conditions and ASA score, delayed VHR is independently associated with worse outcomes. Prompt repair after appropriate resuscitation should be the management of choice.

Surgery for incarcerated hernia: short-term outcome with or without mesh

BACKGROUND

Incarcerated hernias represent about 5-15 % of all operated hernias. Tension-free mesh is the preferred technique for elective surgery due to low recurrence rates. There is however currently no consensus on the use of mesh for the treatment of incarcerated hernias, especially in case of bowel resection.

AIM

The aims of this study were (i) to report our current practice for the treatment of incarcerated hernias, (ii) to identify risk factors for postoperative complications, and (iii) to assess the safety of mesh placement in potentially infected surgical fields.

METHODS

This retrospective study included 166 consecutive patients who underwent emergency surgery for incarcerated hernia between January 2007 and January 2012 in two university hospitals. Demographics, surgical details, and short-term outcome were collected. Univariate analysis was employed to identify risk factors for overall, infectious, and major complications.

RESULTS

Eighty-four patients (50.6 %) presented inguinal hernias, 43 femoral (25.9 %), 37 umbilical hernias (22.3 %), and 2 mixed hernias (1.2 %), respectively. Mesh was placed in 64 patients (38.5 %), including 5 patients with concomitant bowel resection. Overall morbidity occurred in 56 patients (32.7 %), and 8 patients (4.8 %) developed surgical site infections (SSI). Univariate risk factors for overall complications were ASA grade 3/4 (P = 0.03), diabetes (P = 0.05), cardiopathy (P = 0.001), aspirin use (P = 0.023), and bowel resection (P = 0.001) which was also the only identified risk factor for SSI (P = 0.03). In multivariate analysis, only bowel incarceration was associated with a higher rate of major morbidity (OR = 14.04; P = 0.01).

CONCLUSION

Morbidity after surgery for incarcerated hernia remains high and depends on comorbidities and surgical presentation. The use of mesh could become current practice even in case of bowel resection.

WSES guidelines for emergency repair of complicated abdominal wall hernias

Emergency repair of complicated abdominal hernias is associated with poor prognosis and a high rate of post-operative complications.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bergamo in July 2013, during the 2nd Congress of the World Society of Emergency Surgery with the goal of defining recommendations for emergency repair of abdominal wall hernias in adults. This document represents the executive summary of the consensus conference approved by a WSES expert panel.